This application seeks to extend findings from a previous randomized controlled trial, funded by NIMH (Enhancing Quality in Expanded School Mental Health;1R01MH71015-01A1;2003 -2007), which resulted in the development and refinement of a systematic and achievable strategy for promoting high quality, evidence- based services by clinicians working in school mental health (SMH) programs in Delaware, Maryland, and Texas. In the prior study, clinicians assigned to systematic Quality Assessment and Improvement (QAI) as compared to a condition focused on personal wellness were more likely to engage in evidence-based practices and to demonstrate quality indicators associated with best practice in SMH. However in this study, involving a formative evaluation, distal impacts on emotional/behavioral functioning by students being treated by clinicians were not shown. The failure to achieve student-level impacts was likely related to the formative evaluation, with study procedures enhanced but evolving from Year 1 to Year 2, and to the multi-site study, which contributed error variance. In addition, the prior study did not involve implementation support to assure that clinicians were applying learned skills in their schools. In this follow-up study, we proposed to evaluate an enhanced quality assessment and improvement (EQAI) intervention involving four components: 1) Implementation support (IS), involving on-site coaching including rehearsal, feedback, emotional support, and administrative support based on research and a theoretical model developed by the National Implementation Research Network (with leaders Dean Fixsen and Karen Blase helping to develop IS and on the study's Advisory Panel), 2) systematic QAI to ensure that clinicians are most effectively implementing learned skills in the environment of schools, 3) family engagement and empowerment (FEE) based on recent research through an NIMH Developing Center to study co-investigator, Kimberly Hoagwood and colleagues, and 4) evidence- based practice (EBP) focusing on disruptive behavioral problems through an expanded modular intervention, developed in consultation with study Advisory Panel member, Bruce Chorpita. The study will be implemented in the largest and most successful SMH program in South Carolina (SC), operating in Horry County, with 36-40 full-time clinicians randomly assigned to either EQAI or PW, with both conditions well-developed through the prior R01. The study will measure impacts on proximal outcomes of clinician demonstration of skills in EBP, quality of SMH services, and FEE, and measure distal impacts including student emotional/behavioral functioning, school behavior and performance, and parenting stress. Moderating and/or mediating influences such as clinician experience, attitudes toward evidence-based practice, working alliance with families, and clinician stress will also be explored. With expected positive findings, the study is positioned to have a transformative impact since SC is a leading state for SMH, with almost half of the schools including comprehensive services, and strong local/state support for the study and generalizing findings from it. PUBLIC HEALTH RELEVANCE: In a well established school mental health program operating in a South Carolina school district of 44 schools, will study the impact of an Enhanced Quality Assessment and Improvement (EQAI) intervention designed to improve the effectiveness of services. The EQAI intervention is based on theory and prior research and extends important research on implementing high quality mental health prevention and intervention in the real world setting of schools.